This can be performed without anesthesia as an office procedure or under general anesthesia at initiation of a colorectal procedure to define the level of a rectal lesion, during examination of the anorectal region under anesthesia, and at the time of routine surgery for benign anal conditions (e.g., hemorrhoidectomy, fissure-in-ano) to check for any pathology in the lower rectum. The objective is to examine the rectum into the lower sigmoid colon up to 25 cm to define any lesion(s) and perhaps biopsy these. Preferably the patient would have been prepared with an enema to clear the rectum.

The procedure is best performed by an experienced surgeon, with an assistant or a nurse, with a long suction catheter and biopsy forceps available.

Rigid sigmoidoscopy may also be used to decompress a sigmoid volvulus. This may be performed either on the patient’s bed or on the operating table, and it is essential that adequate preparation is given in anticipation of large volumes of feculent fluid coming through the sigmoidoscope. The availability of suction and a rectal tube is mandatory.

The anorectal anatomy is usually constant but can be altered by abscesses, sepsis, fissure, fistula, rectal tumors, pelvic pathology, and sigmoid colon pathology, including diverticular disease, strictures, volvulus, intussusception, and tumors. The lower rectum is directed backwards, the mid-rectum upwards, and then the upper rectum forwards.

See Table 2.1. Rectal perforation is the most serious complication. This may be either extraperitoneal or intraperitoneal and should be recognized by the operator as a tear associated with bleeding. This most commonly occurs when an inexperienced operator is performing the procedure, when undue force is used, or when the rectum or sigmoid is fixed by either a tumor or an inflammatory process. Extraperitoneal perforation may not require any surgery, whereas intraperitoneal perforation is more serious and may require colonic defunctioning for diversion of the fecal stream. The risk of perforation from colonoscopy is approximately double that from sigmoidoscopy. Hemorrhage following biopsy may also occur and is more likely to occur in biopsying normal rectal mucosa than biopsying tumors. Overall, infection is rare, but perineal necrotizing fasciitis or Fournier’s gangrene is reported. Discomfort from insufflation of gas or instrument insertion is common, and the patient should be warned of this.

Major complications are very rare. The procedure is usually very straightforward. Rectal tears and/or bowel perforation may rarely occur, potentially leading to local sepsis, abscess formation, and sometimes systemic sepsis and very rarely multi-system organ failure. Bleeding may be severe especially after biopsy, sometimes associated with anticoagulant therapy or bleeding diatheses. Particular care should be taken in immunosuppressed patients, those with ulcerative colitis and carcinoma, following radiation therapy and rectosigmoid tethering, or where vision is obscured by blood or feces. The need for general anesthesia and further surgery is possible if a severe injury occurs and requires diversion colostomy/ileostomy and/or repair.

This procedure is ideally performed under general anesthesia or IV sedation in the presence of a qualified anesthetist for adequate monitoring. This provides the patient with adequate relaxation, analgesia, and the ability for the assistant to aid the endoscopist in providing pressure or changing the posture of the patient from lateral to lithotomy or even to prone position while maintaining the airway. Occasionally, no anesthesia is required. Preoperative preparation of the bowel is mandatory to provide adequate views and to reduce the chances of complication.

The basic anatomy of the anus, rectum, and colon is relatively constant; however, the length and tortuosity of various sections of the colon (notably the sigmoid and transverse colon) may vary considerably. The cecum may also be very mobile. The hepatic and splenic flexures and sigmoid loop may be tethered and make negotiation with the colonoscope difficult.

See Table 2.2. Colonoscopy in experienced hands is a relatively safe procedure. However, because perforation is such a significant complication, the informed consent process is vital so that the patient has full understanding of the risks.

The risks of perforation are significantly increased when therapeutic endoscopy is performed using either the “hot biopsy” technique or the snare and diathermy technique. Therapeutic biopsy-related perforations are more likely in the right colon, and perforation associated with diagnostic colonoscopy is more likely in the left colon, particularly in the sigmoid. The overall risk of perforation is about 1:1,000.

Early recognition and aggressive management of perforations following flexible endoscopy is vital to reduce long-term septic complications. Extraperitoneal perforations are usually less serious but may require antibiotics in addition to careful observation, whereas intraperitoneal perforation may require surgical intervention, including laparotomy and colostomy or ileostomy to divert the fecal stream in some cases, with or without resection or oversewing of the perforation site. The risk of perforation from colonoscopy is approximately double that from sigmoidoscopy. Bleeding is rarely severe, but a small amount of bleeding after biopsy is not uncommon.

Colonoscopy is usually a straightforward procedure. Major complications are rare but include full-thickness perforation of the rectum or colon, which can require further surgery (laparotomy or per-anal procedure). Local infection, abscess formation, fistula, systemic sepsis, and multi-system organ failure may follow perforation. Particular care should be taken in immunosuppressed patients, those with ulcerative colitis and carcinoma, following radiation therapy and rectosigmoid tethering, or where vision is obscured by blood or feces. Hypoxia from sedation is rare, and brain damage exceedingly rare with the use of oxygen monitors and an anesthetist supervising. Severe bleeding is uncommon, but can rarely require blood transfusion or further surgery. Failure to diagnose is possible, and inability to complete the full colonoscopy is not uncommon, related to the anatomy, previous surgery, bowel preparation, and experience of the colonoscopist. A repeat colonoscopy or another method may be required. Although rare, aspiration pneumonitis can be a serious and lethal complication but is reduced by an adequate fasting period and good airway management.

General anesthesia is used. The patient is positioned in the supine position and is best examined when anesthetized to assess whether there is a mass to determine the best site for the incision. Rectal examination under anesthesia may be useful to assess the presence of any pelvic mass particularly in the female.

The objective of the operation is to perform removal of the appendix and also to examine the pelvis for pelvic pathology, particularly in the female, and the terminal ileum for the presence of a Meckel’s diverticulum or other pathology causing local peritonitis, particularly if the appendix appears normal. Occasionally, the inflammatory process, phlegmon or abscess, is so extensive that the appendix cannot be removed, and it may be judicious to simply drain the abscess.

Under most circumstances the appendix can be removed using a transverse (Lanz) skin incision and a muscle splitting incision of the internal oblique and transversus muscles. When other pathology is encountered, either Crohn’s disease affecting the terminal ileum and cecum, diverticular disease affecting the sigmoid colon or cecum, or an abscess involving the right fallopian tube, ovary, and uterus, the incision may be extended or an alternative midline incision performed.

The surgical approach in open appendectomy is a paradox in that it disobeys the primary principle of abdominal surgery that being adequate access and exposure. A small incision is often made to obtain a good cosmetic result, making access more difficult. Surgeons should never hesitate to increase the length of the skin incision and divide the abdominal muscles to provide better access to the peritoneal cavity. Under these circumstances, the cecum should be mobilized by dividing the congenital adhesions to bring the cecum well into the wound to show the display and full length of the appendix, particularly its junction with the cecum.

The appendix origin lies at the confluence of the taenia coli; however, its tip can vary enormously in position, lying retrocecally (~75 % cases), pelvic (20 %), or retro-ileal/pre-ileal (5 %). The length of the appendix varies also and can reach the upper ascending colon posteriorly. The appendix and cecum may enter a large inguinal hernia sac. An inflamed appendix, if retrocecal or pelvic in location, may irritate the ureter. Hematuria or dysuria may occur. Irritation of the bladder or colon can cause urinary urgency and/or diarrhea. Irritation of the psoas muscle by an inflamed retrocecal appendix or abscess may cause hip discomfort on movement. Maldescent of the appendix is rare, due to malrotation of the cecum, which remains high in the hepatic region. Agenesis, duplication, and situs inversus (L-side appendix) are exceedingly rare but can occur.

See Table 2.3. Infective complications are the most common following appendectomy, wound infection being the most significant. This may be minimized by adequate exposure, preoperative prophylactic antibiotics, and copious lavage of the abdominal cavity and the wound with large volumes of warm saline.

In grossly contaminated (dirty) wounds, drainage of the pelvis and wound, delayed primary skin closure, or the use of gauze pledgets impregnated with antiseptic may be used in an effort to reduce risk of infection. The other option is to leave the skin wound open and use vacuum-assisted dressings.

Abscess formation can occur in the pelvis, right paracolic gutter, between loops of small bowel, or occasionally subphrenic space, but are uncommon. Damage to anatomical structures in the region may occur, particularly the ilioinguinal or iliohypogastric nerves as they traverse close to the incision or the inferior epigastric vessels. Right inguinal hernia and right femoral hernia are more common after appendectomy.

Different techniques of dealing with the appendix stump can avoid complications associated with the stump including intraperitoneal abscess, “recurrent” appendicitis, and fecal fistula from breakdown of the wound closure of the cecum. Moreover, long-term complications of small bowel obstructions with adhesions either to the appendix base or to the aperture of the appendix mesentery can occur. Inversion of the stump has been associated with increased risk of small bowel obstruction. Firm suture transfixion/ligation of the appendix base against the cecum usually avoids appendix stump complications. Complete appendectomy with transection of the appendix flush with the cecum and closure in two layers with a monofilament absorbable suture will eliminate an appendix stump.

Serious complications are abscess formation, fistula or sinus formation, and systemic sepsis, which may rarely lead to multi-system organ failure and even mortality. Early surgery and preoperative antibiotics have reduced these complications significantly. Preexisting comorbidities including age, established generalized peritonitis, and immunosuppression can increase risk of infection greatly. Wound infection may be reduced by delaying skin closure for several days. Further surgery may be warranted. Severe bleeding is rare, and transfusion uncommon. Concealed postoperative bleeding is rare. Persistent wound sinuses or a fecal fistula requires prolonged hospitalization and dressings but most close within 2 months. Prolonged ileus and later (even decades later) small bowel obstruction can occur, but are surprisingly uncommon even with extensive adhesions. The possibility of a laparotomy and even a colostomy should be mentioned, should other pathology be found, although uncommon. Nerve injury, either at surgery or later scar adhesions, can cause severe discomfort and rarely chronic pain problems. Incisional hernia formation is more common after wound infection and/or dehiscence. Ureteric injury or iliac arterial injury is exceedingly rare, although reported, but can be catastrophic.

General anesthetic is used. The patient is positioned in the supine position and is best examined when anesthetized to assess whether there is a mass to determine the best site for the incision. Rectal examination under anesthesia may be useful to assess the presence of any pelvic mass. Some surgeons prefer the modified Lloyd-Davies position.

The objective of the operation is to perform removal of the appendix, using the principles of minimal invasive surgery, and should include laparoscopic examination of the peritoneal cavity to examine the pelvis for pelvic pathology, particularly in the female, and the terminal ileum for the presence of a Meckel’s diverticulum or other pathology causing local peritonitis, particularly if the appendix appears normal. Occasionally, the inflammatory process, phlegmon or abscess, is so extensive that the appendix cannot be removed and it may be judicious to simply drain the abscess.

When other pathology is encountered, either Crohn’s disease affecting the terminal ileum and cecum, diverticular disease affecting the sigmoid colon or cecum, or an abscess involving the right fallopian tube, ovary, and uterus, an alternative approach and open surgery may be preferred.

Surgeons should never hesitate to convert to an open incision if the safety of the operation is jeopardized through increased risk of injury, progress is poor, or vision is inadequate.

The appendix origin lies at the confluence of the taenia coli; however, its tip can vary enormously in position, lying retrocecally (~75 % cases), pelvic (20 %), or retro-ileal/pre-ileal (5 %). The length of the appendix varies also and can reach the upper ascending colon posteriorly. The appendix and cecum may enter a large inguinal hernia sac. An inflamed appendix, if retrocecal or pelvic in location, may irritate the ureter. Hematuria or dysuria may occur. Irritation of the bladder or colon can cause urinary urgency and/or diarrhea. Irritation of the psoas muscle by an inflamed retrocecal appendix or abscess may cause hip discomfort on movement. Maldescent of the appendix is rare, due to malrotation of the cecum, which remains high in the hepatic region. Agenesis, duplication, and situs inversus (L side appendix) are exceedingly rare but can occur.

See Table 2.4. Infective complications are the most common following appendectomy, wound infection being the most frequent. Use of a bag to collect and contain the appendix for removal may reduce risk of infection. Adequate exposure, good port placement, preoperative prophylactic antibiotics, and copious lavage of the abdominal cavity and the wounds with large volumes of warm saline may also assist. In grossly contaminated (dirty) wounds, drainage of the pelvis and wound, delayed primary skin closure, or the use of gauze pledgets impregnated with antiseptic may be used in an effort to reduce risk of infection. Abscess formation can occur in the pelvis, right paracolic gutter, between loops of small bowel, or occasionally subphrenic space, but are uncommon. Gas embolism is associated with Veress needle insertion, which can be virtually eliminated by open cutdown methods. Similarly, injury to the bladder, bowel, or vessels during port insertion can usually be avoided by open cutdown insertion methods. Emptying the bladder is mandatory before port placement. Pneumothorax is a rare, idiosyncratic complication, probably from diaphragmatic leakage of gas.

Abscess formation, fistula or sinus formation, and systemic sepsis are serious complications that may rarely lead to multi-system organ failure and even mortality. Early surgery and preoperative antibiotics have reduced these complications significantly. Preexisting comorbidities including age, established generalized peritonitis, and immunosuppression can increase risk of infection greatly. Wound infection may be reduced by delaying skin closure for several days. Further surgery may be warranted. Severe bleeding is rare, and transfusion uncommon. Concealed postoperative bleeding is rare. Persistent wound sinuses or a fecal fistula requires prolonged hospitalization and dressings but most close within 2 months. Prolonged ileus and later (even decades later) small bowel obstruction can occur, but are surprisingly uncommon even with extensive adhesions. The possibility of a laparotomy, and even a colostomy should be mentioned, if other pathology is found, although uncommon. Nerve injury, either at surgery or later scar adhesions, can cause severe discomfort and rarely chronic pain problems. Gas embolism is a very rare but catastrophic complication. Incisional hernia formation is more common after wound infection and/or dehiscence. Ureteric injury or iliac arterial injury is exceedingly rare but can be catastrophic.

General anesthetic is used. The patient is often best positioned in the modified Lloyd-Davies position with a urinary catheter in the bladder. This provides access to the anus and rectum, should this be required, and also provides access for the scrubbed nurse during the operation or the surgeon to gain easier access to the left upper quadrant particularly to perform mobilization of the splenic flexure. Preoperative sitting, ideally by a stomal therapy nurse, is highly recommended.

Colostomy and mucous fistula is most often performed with colonic resection, where conditions mitigate against performing a primary anastomosis or where subtotal colectomy with ileorectal anastomosis is contraindicated. To make the later second stage of the procedure, viz., colo-colonic anastomosis, more straightforward, it is best that the proximal colon and distal colon are brought out through the same aperture. Ideally, the site of the stoma is planned before the operation commences. In an emergency setting, this is not possible, and the aperture of the stoma is best placed in a horizontal plane, along a line from the umbilicus to the anterior superior iliac spine, approximately 3–4 cm lateral to the umbilicus usually on the left side. The stoma should ideally go through the rectus muscle. It is important to align the fascia/muscle/skin openings so as not to “scissor” the opening which can cause outlet obstruction. Designing the correct sized opening for the bowel caliber is vital to avoid narrowing due to a too small opening or prolapse/hernia due to a too large opening. The pathology, degree of bowel edema, and anatomical location (e.g., colon vs. ileum) can influence this at the time of surgery.

The abdomen is closed and the stomata are fashioned together at the skin surface using absorbable suture material.

The colon length and mobility may vary considerably. This may be partially determined by the peritoneal attachments and adhesions from previous surgery or inflammation. The mesenteric length may also vary, often shortened by disease processes, such as diverticular disease. Intraperitoneal, extraperitoneal, and body wall fat may also limit the ability to raise bowel to the skin easily. Thick abdominal muscle may tend to constrict the stoma.

See Table 2.5. Relief of obstruction and control of infection usually make major complications infrequent, and complications are often minor in nature. Without surgery, consequences are usually dire. Ischemia of the colostomy in the immediate postoperative period is the most serious complication and can be best avoided by making the aperture of adequate size and ensuring arterial blood supply to the proximal cut end of the colon. Because the colostomy is fashioned after abdominal closure, it is vital to ensure adequate length of colon can be brought out through the aperture to create the colostomy. This may require mobilization of the splenic flexure, which would be a mandatory procedure for any resection of the left colon. Retraction of the stoma due to distension is another potential complication due to traction and may also cause ischemia. Fecal leakage is usually avoidable but can occur, leading to infection and abscess formation. Separation of the mucosa and skin may occur particularly in patients with medical comorbidities and malnutrition and when taking medication that may reduce wound healing. The involvement of the stomal therapist in the preoperative and postoperative phases is essential. Longer-term complications include leakage from stoma from poor appliance fit. Reversal of the double-barreled colostomy is usually desired; however, some circumstances may make this unwise, for example, in elderly and patients with significant comorbidities who are at high risk.

Stomal and colonic ischemia are serious complications of both stomal constriction and tension on the bowel, potentially associated with any devascularization during dissection. These are usually avoidable, or reducible, risks. Bowel necrosis and fecal leakage are potential consequences, leading to wound infection and peritonitis, often with abscess formation and possibly fistula formation. Systemic sepsis and consequent multi-system organ failure may supervene, both associated with significant morbidity and mortality. Early reoperation for stomal revision may avoid this. Ureteric injury and vascular injury are rare, unless a colonic mass is attached to the retroperitoneum and ureter. Further surgery at the time and after may then be required. Infection is associated with a greater risk of later stomal and wound hernia formation. Local complications such as fistula formation, cellulitis, and external leakage can be major for the patient and staff.

General anesthetic is usually used; however, local or spinal anesthesia may be used for elderly and infirmed patients. The patient is positioned either in supine or in the Lloyd-Davies position (as described above) with a urinary catheter in the bladder. Preoperative sitting, ideally by a stomal therapy nurse, is highly recommended. In an emergency setting, siting the stoma may not be possible, and the aperture of the stoma is best placed in a horizontal plane, in either the right upper quadrant for a transverse colon loop or left lower quadrant for a sigmoid loop. The stoma should ideally go through the rectus muscle.

The objective of this operation is to perform a defunctioning stoma. There is considerable debate as to whether a loop colostomy or a loop ileostomy is a better method of defunctioning, whatever the indication. Many colorectal surgeons prefer loop ileostomy because it preserves the colon and its blood supply, not compromising any future surgery on the colon.

The dilemma is that whereas a loop colostomy is associated with significant complications particularly of prolapse and parastomal hernia, it is associated with fewer complications with the closure. Whereas loop ileostomy has fewer complications of prolapse and parastomal hernia, and often defunctions more efficiently than loop colostomy, there are more significant complications associated with the closure of the loop ileostomy. If a loop colostomy is chosen, obtaining an adequate length of viable colon is mandatory for the success of the stoma. A rod is used to support the loop colostomy in the immediate postoperative period to avoid stomal retraction. Different devices can be used for the rod. A flexible plastic catheter (e.g., FG8 infant feeding tube) is quite useful. The full-length tube can be used to pull the colon out through the aperture and then cut to size, and each end is sutured to the skin with nonabsorbable sutures and removed at ~10 days. It is important to align the fascia/muscle/skin openings so as not to “scissor” the opening which can cause outlet obstruction. Designing the correct sized opening for the bowel caliber is vital to avoid narrowing due to a too small opening or prolapse/hernia due to a too large opening. The pathology, degree of bowel edema, and anatomical location (e.g., transverse vs. sigmoid colon) can influence this at the time of surgery.

The transverse colon is often selected in the right upper abdomen, although any mobile section of colon can be used (e.g., sigmoid). The position of the transverse colon may vary considerably, and a plain abdominal x-ray or CT scan may assist in preoperative localization. The stomal site should not be too close to the costal margin or umbilicus to permit better adherence of the stoma bag and reduce leakage. The omentum or small bowel may obscure the colon, and a very redundant (sigmoid) colon or cecum can be confusing, especially if dilated. Adhesions from past surgery can tether the colon and reduce mobility.

See Table 2.6. Loop colostomy is usually a straightforward procedure, associated with mainly minor complications, and can effectively defunction the colon and usefully relieve a colonic obstruction. On occasions, the stoma may “valve” and not work well. Ischemia of the stoma in the initial postoperative period is the most significant problem and is avoided by using the principle outlined above. Long-term problems with prolapse and peristomal hernia formation are almost universal with loop colostomy. If a colostomy is chosen as a permanent form of defunctioning, then an end colostomy of the proximal colon and staple closure of the distal colon is probably preferable. If, however, a loop colostomy is being used for a distal rectal perforation, then it is mandatory to lavage the bowel distal to the defunctioning loop colostomy to remove all fecal material. This will make the loop colostomy more efficient in its primary indication to decompress and defunction the distal rectum. Longer-term complications include leakage at the stoma from poor appliance fit.

Failure to function to decompress and defunction the more distal colon may require further surgery. Stomal ischemia and perforation with leakage and wound infection may lead to abscess formation, subcutaneously or intraabdominally, sometimes with peritonitis and systemic sepsis. Stomal retraction or prolapse can be major problems requiring revisional surgery. Multi-system organ failure may then occur. Local complications such as fistula formation, cellulitis, and external leakage can be a major problem for the patient and staff.

General anesthetic is used. The patient is placed in the supine position, occasionally the modified Lloyd-Davies position may be used if extended right hemicolectomy is performed. A urinary catheter is placed in the bladder. Preoperative sitting, ideally by a stomal therapy nurse, is highly recommended. In an emergency setting, siting the stoma may not be possible, and the aperture of the stoma is best placed in a horizontal plane in the right iliac fossa adjacent to the umbilicus. The stoma should ideally go through the rectus muscle.

Often, the reason for not performing an anastomosis is the presence of intraabdominal sepsis arising from perforation, typically associated with Crohn’s disease or other inflammatory processes of the ileocecal region. Occasionally, small bowel obstruction associated with malignant or inflammatory processes of the right colon is a reason for right hemicolectomy. Dilatation of the small bowel often mitigates against a safe anastomosis. In any other circumstances where anastomosis is contraindicated, then an ileostomy should be fashioned.

The objective of this operation is to perform mobilization of the right colon, including the cecum, hepatic flexure, and transverse colon from the omentum with control of the blood supply involving ligation of the ileocolic, right colic, and branches of the middle colic artery; resection of the dissected bowel; and creation of an end ileostomy and mucous fistula of the colon.

If a stoma is being considered, a midline incision is performed. For most other operations involving the right colon, an upper transverse incision affords good access.

It is important to align the fascia/muscle/skin openings so as not to “scissor” the opening which can cause outlet obstruction. Designing the correct sized opening for the bowel caliber is vital to avoid narrowing due to a too small opening or prolapse/hernia due to a too large opening. The pathology, degree of bowel edema, and anatomical location (e.g., colon vs. ileum) can influence this at the time of surgery. The authors prefer an end ileostomy with staple closure of the colon. Alternatively, the ileum and colon may be brought out through the same aperture, and the back wall of a tension-free anastomosis created using continuous monofilament absorbable suture material, a rod placed under the suture line (i.e., FG8 infant feeding tube), and a modified Brooke-type ileostomy fashioned. A Brooke ostomy often improves appliance fitting and thereby decreases skin irritation from the ostomy contents and skin contraction. This will make the second stage of the operation, viz., ileocolonic anastomosis, more straightforward, avoiding a formal laparotomy.

The main anatomical variant is malrotation with the cecum in the right upper quadrant. Rarely, situs inversus may occur with the cecum on the left. Pathology may alter anatomy, reducing mobility and producing indurated tissues, sometimes dictating the surgical options.

See Table 2.7. Many of the complications are not particularly severe, and most relate to the stoma itself or sepsis arising from the underlying disease process. Ischemic necrosis of the ileostomy is the most significant problem encountered but often avoided by making an adequate sized aperture of and ensuring arterial blood supply to the ileum and colon before abdominal closure. Longer-term complications include leakage from stoma from poor appliance fit. Although mortality is usually low, in cases with comorbidities, obstructed bowel, or established infection, risk of morbidity and mortality may be significantly increased, and this should be taken into account in these settings.

Stomal ischemia and stomal necrosis represent a spectrum from chronic minor problems to severe stomal retraction, leakage, peritonitis, abscess formation, and fistula formation. Systemic sepsis and very rarely multi-system organ failure may supervene. Small bowel obstruction is an uncommon complication, but can be a severe problem with recurrent episodes and sometimes requiring repeated surgery for division of adhesions. Ureteric injury is very rare, but the cecum and ascending colon are anteriorly related to the right ureter. Further surgery may be required for correction of any of the above problems or for later ileocolic anastomosis to restore bowel continuity.

General anesthetic is used. The patient is placed in the supine position, occasionally the modified Lloyd-Davies position may be used if extended right hemicolectomy is performed. A urinary catheter is placed in the bladder. Either a midline incision or an upper transverse incision may be used.

The objective of this operation is to perform mobilization and resection of the right colon including the cecum, ascending colon, hepatic flexure, and proximal transverse colon with ligation of the blood supply particularly the ileocolic, right colic, and branches of the middle colic with primary anastomosis of the ileum to the transverse colon. Occasionally, this is modified to an ileo-cecectomy (limited right hemicolectomy) with an anastomosis of the ileum to the ascending colon, for example, in patients with complicated Crohn’s disease, cecal inflammation from appendicitis, or solitary cecal diverticulum. For malignant tumors in the right colon, a right hemicolectomy as described above is preferred. Total mesocolic resection is now advocated for colon cancer.

After ensuring adequate arterial blood supply to both cut ends, particularly the colonic end, the anastomosis may be fashioned either with a continuous single-layer suture technique using absorbable monofilament material with the anastomosis marked with nonabsorbable monofilament suture and Weck clips or with functional end-to-end (or side-to-side) anastomosis using the GIA linear stapler.

The main anatomical variant is malrotation with the cecum in the right upper quadrant. Occasionally, situs inversus may occur with the cecum on the left. Pathology may alter anatomy, reducing mobility and producing indurated tissues, sometimes dictating the surgical options.

See Table 2.8. Many of the complications are not particularly severe. Anastomotic breakdown is the most serious complication, potentially avoided by not making an anastomosis if the patient’s condition mitigates against this, ensuring adequate arterial blood supply at both ends of the bowel and avoidance of tension or twisting of the bowel.

Typically, the small bowel diameter is less than that of the large bowel. A longitudinal (Cheatle) slit incising along the anti-mesenteric border of the small bowel can correct the size disparity. For the stapling technique, the bowel ends are stapled at resection and a side-to-side anastomosis is performed, avoiding the problem of incompatibility of the different diameters of the bowel. Although mortality is usually low, in cases with comorbidities, obstructed bowel, or established infection, risk of morbidity and mortality may be significantly increased, and this should be taken into account in these settings.

Anastomotic breakdown with leakage is a serious complication which may result in local sepsis, including abscess formation, or generalized peritonitis. The drainage of an abscess to skin or bowel can result in chronic sinus or fistula formation. Early or late small bowel obstruction may result from either early anastomotic blockage (edema, stenosis, suture misplacement) or from later adhesion formation, which can be a severe problem with recurrent episodes and sometimes requiring repeated surgery for division of adhesions. Twisting of the bowel during anastomotic formation and injury to other organs are technical complications, which can occur but are usually rare. Systemic sepsis and very rarely multi-system organ failure may supervene. Ureteric injury is very rare, but the cecum and ascending colon are anteriorly related to the right ureter. Further surgery may be required for correction of any of the above problems.

General anesthesia is used. Patient is positioned with the urinary catheter in the bladder either in supine or in the modified Lloyd-Davies position. Positioning of the buttocks on the table is important to gain adequate access to the rectum for rectal washout, if necessary. A stomal therapist should preferably be involved in counselling and stomal siting of the patient preoperatively. In the semi-elective setting, this may not be practicable. The ideal site for left iliac fossa colostomy is in horizontal plane 3–4 cm lateral to the umbilicus.

The objective is to resect the (upper) rectosigmoid and close the distal rectal stump and create an end colostomy of the left colon. Elective Hartmann’s procedure is performed in those patients where anastomosis is at high risk of failure, usually in the presence of intraabdominal sepsis or unresectable rectal malignancy, or in a patient with medical comorbidities or medical treatment that mitigates against adequate wound healing. The rectum is usually closed with a linear stapler, and it is vital that a supple part of the rectum with adequate blood supply is chosen to avoid breakdown of the staple closure. It is vital to identify and protect the left ureter from injury during rectosigmoid mobilization, particularly when performing transection of the rectum. Preoperative bowel preparation may be useful, but is often not required.